Episode of care—principal diagnosis, code (ICD-10-AM 6th edn) ANN{.N[N]}

Identifying and definitional attributes

Metadata item type:Data Element
Short name:Principal diagnosis
METeOR identifier:361034
Registration status:Health, Superseded 22/12/2009
Definition:The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment, as represented by a code.
Data Element Concept:Episode of care—principal diagnosis

Value domain attributes

Representational attributes

Classification scheme:International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification 6th edition
Representation class:Code
Data type:String
Format:ANN{.N[N]}
Maximum character length:6

Data element attributes

Collection and usage attributes

Guide for use:

The principal diagnosis must be determined in accordance with the Australian Coding Standards. Each episode of admitted patient care must have a principal diagnosis and may have additional diagnoses. The diagnosis can include a disease, condition, injury, poisoning, sign, symptom, abnormal finding, complaint, or other factor influencing health status.

As a minimum requirement the Principal diagnosis code must be a valid code from the current edition of ICD-10-AM.

For episodes of admitted patient care, some diagnosis codes are too imprecise or inappropriate to be acceptable as a principal diagnosis and will group to 951Z, 955Z and 956Z in the Australian Refined Diagnosis Related Groups.

Diagnosis codes starting with a V, W, X or Y, describing the circumstances that cause an injury, rather than the nature of the injury, cannot be used as principal diagnosis. Diagnosis codes which are morphology codes cannot be used as principal diagnosis.

Collection methods:

A principal diagnosis should be recorded and coded upon separation, for each episode of patient care. The principal diagnosis is derived from and must be substantiated by clinical documentation.

Comments:The principal diagnosis is one of the most valuable health data elements. It is used for epidemiological research, casemix studies and planning purposes.

Source and reference attributes

Origin:

Health Data Standards Committee

National Centre for Classification in Health

National Data Standard for Injury Surveillance Advisory Group

Reference documents:Bramley M, Peasley K, Langtree L and Innes K 2002. The ICD-10-AM Mental Health Manual: an integrated classification and diagnostic tool for community-based mental health services. Sydney: National Centre for Classification in Health, University of Sydney

Relational attributes

Related metadata references:

Supersedes Episode of care—principal diagnosis, code (ICD-10-AM 5th edn) ANN{.N[N]} Health, Superseded 05/02/2008

Has been superseded by Episode of care—principal diagnosis, code (ICD-10-AM 7th edn) ANN{.N[N]} Health, Superseded 02/05/2013, Tasmanian Health, Draft 23/07/2012, Commonwealth Department of Health, Candidate 16/07/2015, National Health Performance Authority (retired), Retired 01/07/2016

Implementation in Data Set Specifications:
All attributes +

Acute coronary syndrome (clinical) DSS Health, Superseded 01/09/2012

Admitted patient care NMDS 2008-09 Health, Superseded 04/02/2009

DSS specific attributes +

Admitted patient care NMDS 2009-10 Health, Superseded 22/12/2009

DSS specific attributes +

Admitted patient mental health care NMDS 2008-09 Health, Superseded 04/02/2009

DSS specific attributes +

Admitted patient mental health care NMDS 2009-10 Health, Superseded 05/01/2010

DSS specific attributes +

Admitted patient palliative care NMDS 2008-09 Health, Superseded 04/02/2009

DSS specific attributes +

Admitted patient palliative care NMDS 2009-10 Health, Superseded 05/01/2010

DSS specific attributes +

Community mental health care NMDS 2008-09 Health, Superseded 04/02/2009

DSS specific attributes +

Community mental health care NMDS 2009-10 Health, Superseded 05/01/2010

DSS specific attributes +

Residential mental health care NMDS 2008-09 Health, Superseded 04/02/2009

DSS specific attributes +

Residential mental health care NMDS 2009-10 Health, Superseded 05/01/2010

DSS specific attributes +
Implementation in Indicators:Used as numerator
National Healthcare Agreement: PB 07-By 2014-15, improve the provision of primary care and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over the 2006-07 baseline to 8.5 per cent of total hospital admissions, 2011 Health, Superseded 30/10/2011
National Healthcare Agreement: PB 07-By 2014-15, improve the provision of primary care and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over the 2006-07 baseline to 8.5 per cent of total hospital admissions, 2012 Health, Superseded 25/06/2013
National Healthcare Agreement: PI 04-Incidence of selected cancers, 2011 Health, Superseded 30/10/2011
National Healthcare Agreement: PI 04-Incidence of selected cancers, 2012 Health, Superseded 25/06/2013
National Healthcare Agreement: PI 22-Selected potentially preventable hospitalisations, 2011 Health, Superseded 31/10/2011
National Healthcare Agreement: PI 22-Selected potentially preventable hospitalisations, 2012 Health, Superseded 25/06/2013
National Healthcare Agreement: PI 41-Falls resulting in patient harm in hospitals, 2011 Health, Superseded 31/10/2011
National Healthcare Agreement: PI 41-Falls resulting in patient harm in hospitals, 2012 Health, Retired 25/06/2013
National Healthcare Agreement: PI 42-Intentional self-harm in hospitals, 2011 Health, Superseded 31/10/2011
National Healthcare Agreement: PI 42-Intentional self-harm in hospitals, 2012 Health, Retired 25/06/2013
National Healthcare Agreement: PI 43-Unplanned/unexpected readmissions within 28 days of selected surgical admissions, 2011 Health, Superseded 31/10/2011
National Healthcare Agreement: PI 43-Unplanned/unexpected readmissions within 28 days of selected surgical episodes of care, 2012 Health, Superseded 25/06/2013
National Healthcare Agreement: PI 57-Hospital patient days used by those eligible and waiting for residential aged care, 2011 Health, Superseded 31/10/2011
National Healthcare Agreement: PI 57-Hospital patient days used by those eligible and waiting for residential aged care, 2012 Health, Superseded 25/06/2013
National Healthcare Agreement: PI 62-Hospitalisation for injury and poisoning, 2011 Health, Superseded 31/10/2011
National Healthcare Agreement: PI 62-Hospitalisation for injury and poisoning, 2012 Health, Retired 25/06/2013
National Indigenous Reform Agreement: PI 11-Child under 5 hospitalisation rates by principal diagnosis, 2011 Indigenous, Archived 01/07/2012
National Indigenous Reform Agreement: PI 11-Child under 5 hospitalisation rates by principal diagnosis, 2012 Indigenous, Archived 13/06/2013